Does Z12.0 require prior authorization?

No, Z12.0 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`Z12.0`, Encounter for screening for malignant neoplasm of stomach

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

No explicit documentation requirements are stated in this Clinical Policy Bulletin.
Record of the chosen diagnostic test and FDA clearance status: e.g., stool antigen test (HpSA) cleared for initial diagnosis, therapeutic monitoring and eradication confirmation in adults and children; urea breath test cleared for initial diagnosis and eradication confirmation in adults.
If urea breath test is used, documentation that the test was performed while fasting.

For patients requiring endoscopic evaluation (age >55 or alarm symptoms), documentation should include endoscopy report and biopsy-based test results (rapid urease test, histology, culture) when applicable.

Key Coverage Criteria

None specified. Aetna considers the analysis of volatile organic compounds experimental and investigational for the indications listed below (see Limitations).
Confirmation of the presence of the H. pylori bacterium can be determined non-invasively using an FDA-cleared urea breath test or a stool antigen test or invasively on endoscopic biopsy followed by rapid urease testing (CLOtest™, PyloriTek™, Hpfast™), histology with special stains, or culture.
Adults with idiopathic thrombocytopenic purpura
Antibiotic therapy is indicated for all H. pylori -infected ulcer patients.
The stool antigen test (HpSA, Meridian Bioscience, Cincinnati, OH) and the urea breath tests (UBT (Meretek Diagnostics, Lafayette, CO), PYtest (Halyard Health, Alpharetta, GA)) determine the presence of active H. pylori infection.
The HpSA stool antigen test is cleared by the U.S. Food and Drug Administration (FDA) for use in the initial diagnosis, therapeutic monitoring and eradication confirmation in adults and children.

6 Active Policies

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0029, Thermography

AETNA-CPB-0171, Magnetic Resonance Imaging (MRI) of the Extremities

AETNA-CPB-0177, Helicobacter Pylori Infection Testing

AETNA-CPB-0608, Salivary Tests

AETNA-CPB-0717, Analysis of Volatile Organic Compounds

`Z12.0`, Encounter for screening for malignant neoplasm of stomach

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

Z12.0, Encounter for screening for malignant neoplasm of stomach

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

`Z12.0`, Encounter for screening for malignant neoplasm of stomach